Provider Demographics
NPI:1538122817
Name:LARSEN, PETER JON (PA)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:JON
Last Name:LARSEN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8675 VALLEY CREEK RD
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-2337
Mailing Address - Country:US
Mailing Address - Phone:651-241-3000
Mailing Address - Fax:
Practice Address - Street 1:1285 NININGER RD
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MN
Practice Address - Zip Code:55033-1086
Practice Address - Country:US
Practice Address - Phone:651-480-4200
Practice Address - Fax:651-480-4434
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9355363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN040965100Medicaid
MN42990800OtherGROUP HEALTH EAU CLAIRE
MN01-13610OtherMEDICA
MN970015689OtherRAILROAD MEDICARE
MNNA9141022759OtherPREFERRED ONE
MN127666OtherUCARE MINNESOTA
MN16F30LAOtherBLUE CROSS
MNHP30168OtherHEALTH PARTNERS
MN850267OtherAMERICA'S PPO
MN01-13610OtherMEDICA
MN970000696Medicare ID - Type Unspecified